UNFOLDING CASE STUDY

Jeannie Beaumont (J. B.) is a 68-year-old retired schoo lteacher who lives alone. Her daughter came to visit her and called 911 when J. B. was having difficulty responding to
questions, slurring her speech, and was experienc ing right-sided weakness. Her past medical history includes a hysterectomy, hypertension, hypercholesterolemis, and
atrial fibrillation. She has a family history of diabetes, heart disease, and colon cancer. She is widowed and has three adult ch dren who live nearby. Up until now, she has
been independent at home.
Upon arrival at the emergency department, J. B. was alert and oriented to person, place, ice, time, and situation. She was speaking slowly and slurring words. Her right-
hand grasp was weaker than her left-hand grasp and her right leg was weak. She is 167.6 cm (86 in) tall and weighs 65 kg (143 lbs). Her blood pressure was 172/90, pulse
106 and irregular, respirations 20 unlabored, and tempera ture 36.5° C (97 8° F), oxygen saturation 90% on room air. J. B. complains of a headache. Her Johns Hopkins
Hospital (JHH) fall risk assessment score is 10. An electrocardiogram (EKG) revealed atrial fibrillation without ST elevation. A computed tomography (CT) scan was ordered
and results indicated no acute bleeding. She has no known drug allergies and is a full code. Laboratory results were as follows:
Complete blood count (CBC): White blood matocrit 38.1%, platelets 201,000 x 10
cells (WBCS) 4.8/mm², red blood cells (RBCs) 4.2 x 10/µL, hemoglobin 12.6 g/dl, he
Basic metabolic panel (BMP): Blood urea nitrogen (BUN) 14 mg/dL, creatinine 0.9 mg/dl, sodium 139 mEq/L, potassium 3.8 mEq/L, chloride 101 mEq/L, glucose 84 mg/dL,
bicarbonate 21 mEq/L
Magnesium: 1.8 mEq/L
Calcium: 9.7 mg/dl.
Coagulation studies: prothrombin time (PT) 13.5 seconds, international normalized ratio (INR) 1.4
Cardiac proteins: Troponin I 0.02 nanograms/mL., Troponin T 0.08 nanograms/mL
Lipids: Total cholesterol 160 mg/dl, triglycerides 90 mg/dL, HDL 63 mg/dL, LDL. 97 mg/dL
d. B. is admitted to the medical-surgical stepdown unit for observation with a diagnosis of rule out cerebral vascular accident (CVA,
stroke) or transient ischemic attack (TIA).
Treatment orders are as follows:
Consult physical therapy (PT). Strict bed rest until cleared by PT, then activity level as directed by PT.
Vital signs and neurologic assessment every hour x 24 hours, then every 4 hours.
Monitor cardiac rhythm.
Oxygen per nasal cannula: titrate to greater than 92% saturation.
Diet: Dysphagia screening completed by speech therapist or RN prior to any oral intake or medications given. If fails dysphagia
screen, nothing by mouth (NPO). If passes dysphagia screen, may start on soft heart-healthy diet.
Fall precautions
Consult occupational therapy (OT), speech therapy (ST) for evaluation and treatment upon admission.
Consult nutrition services for evaluation and dietary education.
Consult case management for discharge planning.
Medication orders are as follows:
IV 0.9% normal saline (NS) @ 50 mL/hr in left forearm
Metoprolol 25 mg PO twice daily
Apixaban 5 mg PO twice daily
Enalapril 10 mg PO daily
Ezetimibe 10 mg PO at bedtime
Start aspirin 81 mg PO daily

PROBLEM 1

INEFFECTIVE CEREBRAL TISSUE PERFUSION

FDAR - HEADACHE
SOAPIE -

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data:
“Hindi siya makasagot
nang maayos, nabubulol
siya tapos hinang-hina
yung right-side body
niya,” as verbalized by the
SO.
Objective data:
- Speaking slowly and
slurred speech
- Right-sided body
weakness
- Pale in appearance
-Restlessness
Ineffective Cerebral Tissue
Perfusion related to
formation of blood clots
that obstruct the blood
vessels of the brain
After eight hours of 1. Introduce self and role. 1. Establish trust and
nursing interventions, the rapport.
patient will be able to
display decrease signs of 2. Assess and monitor 2. Provide baseline data.
ineffective tissue vital signs, especially BP,
perfusion as evidenced by PR, and SpO2.
gradual improvement of
vital signs. 3. Check capillary refill 3. Evaluation of
and conjunctiva for peripheral perfusion and
paleness. oxygenation status.
4. Assess and monitor 4. Helps in identifying
neurological status, such neurological deficits or
as GCS, level of alterations in cerebral
consciousness and mental perfusion.
 status.
Vital Signs:
- BP: 172/90 mmHg 5. Assess and monitor
- PR: 106 bpm changes in behavior and
- SpO2: 90% speech patterns.
6. Ascertain health history
or condition which may
affect cerebral blood flow.
7. Position properly in
semi-Fowler’s to high
Fowler’s as tolerated.
8. Encourage to have
adequate fluid intake.
9. Advise to maintain bed
rest as ordered.
10. Administer 2-3 LPM
supplemental oxygen via
nasal cannula as ordered.
11. Administer
Metoprolol 25 mg,
Apixaban 5 mg, and
Enalapril 10 mg as
ordered.
5. To measure
appropriateness of
speech content and level
of consciousness.
6. To understand the
factors that might help
with interventions in
optimizing cerebral blood
flow and minimize the risk
of associated
complications.
7. Enhances respiratory
function and reduces the
workload of the heart.
8. To maintain hydration
and supports circulatory
function.
9. Minimizes physical
exertion and promote
cerebral perfusion.
10. Ensures adequate
oxygenation for optimal
tissue perfusion.
11.